In brief:

240 patients with chronic back pain or hip or knee osteoarthritis pain were divided into 2 treatment groups: 1 group received opioids, 1 group received nonopioid medications

After 12 months, researchers found no differences between the groups' reported improvement in function, and a slightly better improvement rate in pain intensity for the nonopioid group

Among individuals who achieved improvements of 30% or more, numbers were nearly equal for the 2 groups in terms of function, and better for the nonopioid group in terms of pain intensity

Authors conclude that given the potential risks associated with opioids, results of the study do not support opioid prescription for chronic back pain or knee or hip osteoarthritis pain

APTA's #ChoosePT opioid awareness campaign makes the case that opioids simply "mask" pain—but a new study in JAMA has concluded that the drugs probably don't even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there's no support for opioid therapy for moderate-to-severe cases of those types of pain.

The published findings (abstract only available for free) are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.

To more closely resemble real-world treatment, researchers used a "treat-to-target" approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.

Participants were monitored throughout the study and evaluated at 12 months using a range of tests, with the primary focus on how pain interfered with function, assessed through the Brief Pain Inventory (BPI); and pain intensity, measured using the BPI severity scale. Both measures are 10-point scales, with higher numbers indicating more pain-related interference or pain intensity. Other areas assessed as secondary outcomes included quality of life, depression, sleep disturbance, headache, anxiety, sexual function, and fatigue.

At the 12-month mark, researchers found no significant differences in pain-related interference between the 2 groups (average BPI function scores of 3.4 in the opioid group and 3.3 in the nonopioid group), and a greater reduction of pain intensity among the nonopioid group (average of 3.5 in the nonopioid group vs 4.0 in the opioid group).

When it came to the achievement of what authors called a "functional response"—a 30% or better improvement in a BPI score—the number of participants who achieved that level of improvement in function was roughly equal among groups, with 69 patients in the opioid group and 71 patients in the nonopioid group reaching the threshold. But the difference was notable in pain intensity scores, with 63 participants in the nonopioid group reporting improvement of 30% or more, compared with 48 participants in the opioid group reaching that level of improvement.

The researchers also analyzed group differences by the type of pain treated:

Back pain

Average score, interference with function: 2.9 in opioid group; 3.3 in nonopioid group

Average score, pain intensity: 3.7 in opioid group; 3.6 in nonopioid group

Hip or knee OA

Average score, interference with function: 4.4 in opioid group; 3.4 in nonopioid group

Average score, pain intensity: 4.5 in opioid group; 3.4 in nonopioid group

Similar to a study published recently, researchers also found that quality-of-life measures did not differ significantly between the 2 groups. The only area in which results from the opioid group bettered the nonopioid group in a notable way was in reduction of anxiety symptoms, although authors point out the only a small number—9% of all participants—reported moderate-to-severe anxiety at baseline.

Authors acknowledged observational studies that associate long-term use of opioids with poor pain outcomes but say that those outcomes may not tell the whole story.

"In this trial, pain-related function improved for most patients in each group," authors write. "Poor pain outcomes associated with long-term opioids in observational studies may be attributable to overprescribing and insufficient pain management resources rather than to direct negative effects of opioids."

Still, they argue, given the "risk for serious harms without sufficient evidence for benefits," there seems to be no compelling reason to even begin a course of opioid-based treatment for certain conditions

Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain-related function over 12 months," authors write. "Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website

Comments

Since we are professionals, Careful not to paint with a broad brush. Know your patient’s individual cases such as activity level, sleep patterns, progression of the disease. I had a total hip replacement about four months ago and in the last three months I took opiates at night because that was the only thing that would reduce the constant ache of joint that would keep me up all night, sleep is important. After the hip replacement I have no pain and back to sports such as mountain biking jujitsu, weight lifting and yoga- without meds!

Posted by Kevin Brown
on 3/8/2018 5:46 PM

As patient with chronic back pain caused by scoliosis and arthritis, I'm a bit skeptical. I've taken hydrocodone when absolutely necessary, but biting off a bit at a time is the best I can so, as I hate the drunken feeling. Nothing really works well. Friends who can take opioids more easily than I are dumbfounded by the claim that Tylenol is as good or superior to various opioids. They suffer real pain and the opioid frenzy is grossly unfair to them.
I'm curious about how many of the non-opioid patients worked their way up to Tramadol, which is now classified as an opioid.

Posted by Gail Holcomb
on 3/13/2018 8:08 PM

Being a chronic back pain patient, I find the results of this very limited study highly questionable. My pain is very real and very limiting. I have tried the otc pain relievers and Tramadol and there was no relief. I do find relief with Norco but only taking one in the morning and one at night and not the third tablet as prescribed. Yes,there is abuse of opioids, but let’s not lose sight of the benefits of these drugs and let’s not condemn or punish the people who take the drugs responsibly.

Posted by Tom Havera
on 3/20/2018 12:11 PM

The publishing of this deceptive, misleading and biased article, shows that a lot of Physical Therapy has little to do with science or facts. Regurgitating this nonsense it gives it credibility. I am disapointed that Physical Therapists who deal with people in pain all of the time, can so callously disregard it. I have also observed that Physical Therapists vary considerably in skill, and ethics. This lack of understanding science, and facts, has me questioning any of their claims. Unfortunately no one has the integrity to ask why no agency tracks the patients injured by Physical Therapy.

Posted by Mavis Johnson
on 8/31/2018 10:14 PM

Had a whole knee replacement and was immediately placed on opioids following surgery, but was doing very poorly - always dizzy and in fear of falling, nightmarish sleep, dull, nauseous, and still had pain that only was bearable with ice. Two days later, felt so bad that I threw out the opioids and decided to try Tylenol, 2 before PT and 2 at bedtime, desperate to feel better. What a difference! A day later, the pain was at a very low, bearable level and all awful side effects were gone. This article does support my experience. Each to his own and his own situation.

Posted by Deborah Holley
on 10/28/2018 9:38 AM

I suffer from chronic back pain. For more than twenty years all I took was otc meds. They helped very little. Chiropractors, massage therapy, exercise and ice packs helped me to keep working and feeling less pain. Had a bowl resection in early 2017 and was prescribed low dosage hydromorphone for a one month period. Wow! My back pain diminished by 95%. After consulting with a pain management doctor , I'm now taking low doses of the same opiat and with much less chiro and massage therapy, and pain is almost 100% gone. I feel it bias and unfair to include responsible opiat users into the same category as those who abuse their prescribed amounts or illegal street drug users. But to each his own, if otc meds work for you, go for it.

Posted by Colin vedell
on 12/18/2018 6:39 PM

Opioids drugs of choice for pain. Reasonable
prescribing and patient monitoring resolves most of problems.

Posted by Alfred Mauro MD
on 1/4/2019 11:04 PM

This article/JAMA "study" is indeed extremely biased and cannot even really be called a scientific study.
Please, read the article via the link below:
https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pny234/5193809?guestAccessKey=faf3ba23-5e5d-4d3d-8e68-8f3b54f2a40a
I hope it's alright to share the link here.
..."These omissions describe the errors in the JAMA article. By specifically excluding patients who had tolerated and presumably benefitted from opioids,..."
"...the investigators studied only participants 1) who had previously tried opioids and discovered they did not respond to them and 2) patients who had never tried opioids because they had previously responded adequately to nonopioid medications."
"Naturally, therefore, the JAMA study achieved the only finding possible: that both opioids and nonopioids reduced pain equally well in patients in whom opioids were not medically indicated. Unfortunately, and probably unintentionally, the authors’ conclusion underplayed the selection bias: “Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip to knee osteoarthritis pain.” This is not a false conclusion, but it is misleading. Accordingly, readers, the mass media, and policy makers did not recognize the selection bias and flawed study design, so they erred in concluding and writing that opioids are no more effective than nonopioids, or worse, that opioids do not even reduce pain but merely create euphoria."

Posted by Kara
on 1/16/2019 2:51 PM

This article is ridiculous and written by someone who doesn't know what they are talking about. If OTC meds. work for you,by all means there is no need for opiates.The fact is for many they just do not work and opiates have been a blessing for millions. Opium products have been around for centuries and some of the greatest figures in history were opiate dependent. It has only been criminalized in the last 100 years and look at the problems it has caused. The worst opiate epidemic was actually right after the Civil War. So many people were dependent it was called "soldiers disease". In 1906 when morphine was made the first illegal drug,10% of the entire population of america was opiate dependent and there was tremendous progress made. Some people are just going to take it to far,just like millions do with ethyl alcohol which by the way is just a drug and is listed in the pharmacopia right along with morphine and every other narcotic. If you don't need them,don't take them because it is a enormous hassle to be on them with all the bias and restrictions.However, many are willing to go through all the hassle because it greatly improves their quality of life. Those are all facts,not just someone's biased opinion.Go look them up for yourself. Opiates are not the "devil" that many make them out to be. Before morphine was made illegal it was used as a cure for alcoholism because it was seen as better to be relaxed on opiates than to be rampaging around town drunk or beating the hell out of your family or whatever. Again these are all facts and I encourage anyone to research it and form their own opinions.The new CDC guidelines are very misguided and have caused a lot of harm as well as a fentanyl epidemic that is killing thousands.The prescription meds. were never the problem,although I agree oxycontin and a few numbskulls got the ball rolling with their ignorant misuse. When the CDC implemented
their new guidelines the heroin dealers were smacking there chops and having a party and now we have the fentanyl thing going on. Which is worse,a couple of bodies a moth for oxycontin OD or a couple of dozen every weekend for fentanyl OD ? Again,go research and find out for yourself. I speak truth.

Posted by Brett bradford
on 1/19/2019 3:41 PM

I just read an article about the VA 30% of the soldier's that were cut down or taken off opioids killed themselves, wow thanks government and you lousy Doctors that won't stand up for you patience. The doctor just needs to keep good track of the paitance. I'm for anything that's gives quilty of life. Doctor's and the government are sending people to the streets to get the meds they need, soon more people will overdose than before. The only ones that will benefit from this mess is the drug dealers. Again government wanting to control us, I say bull shit on the whole mess.

Posted by Jill Strecker
on 2/12/2019 9:40 AM

I think it is important to note that this research did have very restrictive criteria because it was designed to ask a specific question -- If a person has a relatively new onset of pain AND their brain has not been sensitized by long term use of opioids, could OTC pain killers be enough?
This study was not done to assess whether people in chronic pain need opioids. This study was not done to assess whether people whose brains have been exposed to opioid use over 3 months could get similar relief with OTC medications.
This research answers the question it set out to answer. However, it cannot be generalized to chronic pain populations or people who are finding relief with opioids.
It does support the assertion that it is worthwhile to try OTC pain relievers for back, hip and knee pain before progressing to opioids.
The unfortunate fact is that some people generalize the information and apply it to populations not included in the study. Some people overgeneralizing the data does not mean that PTNow is biased for sharing it.